| 6.1.1 Airway support, ventilator assistance and supplemental oxygen |
| Unchanged | Airway support and ventilator assistance are recommended for the treatment of patients with AIS who have decreased consciousness or who have bulbar dysfunction that causes compromise of the airway. | I | C |
| Unchanged | Supplemental oxygen should be provided to maintain oxygen saturation >94%. | I | C |
| Unchanged | Supplemental oxygen is not recommended in non-hypoxic patients with AIS. | III | B |
| 6.1.2 Body temperature |
| Reworded | The cause of fever (body temperature >38°C) should be investigated. Pharmacological antipyretic therapy should be administered to patients who had a stroke who have a fever. | I | C |
| 6.1.3 Nutrition |
| Reworded | Enteral nutrition should be initiated within 7 days of hospitalisation for patients with AIS. | I | B |
| Reworded | For patients with dysphagia, nasogastric tube feeding should be provided during the early stages of stroke (within 7 days of onset). Percutaneous gastrostomy tube placement is considered appropriate when anticipated dysphagia is expected to persist for an extended period (more than 2–3 weeks). | IIa | C |
| Reworded | Nutritional supplements are reasonable for patients who are malnourished or at risk of malnourishment. | IIa | B |
| 6.1.4 Dysphagia |
| New recommendation | Dysphagia screening before the patient begins eating, drinking or receiving oral medications is reasonable, which may help to identify patients at high risk of aspiration. | I | C |
| Dysphagia, a common (37–78%) complication of acute stroke, is a risk factor for aspiration pneumonia and is associated with higher mortality and worse patient outcomes. The Evidence Review Committee completed a systematic review to determine whether dysphagia screening, compared with no screening or usual care, decreased outcomes of pneumonia, death or dependency.108–111 There were insufficient data to determine whether implementing a dysphagia screening protocol reduces the risk of death or dependency. Previous studies found that patients who failed dysphagia screening were older, had a higher rate of multiple comorbidities (including prior stroke and dementia), more often came from a long-term care facility, more often presented with weakness and speech deficits, had a lower level of consciousness and had a higher stroke severity.112 Besides, patients who failed dysphagia screening were more likely to develop pneumonia (13.1% vs 1.9%), to have a more severe disability (52.4% vs 18.0%) and to be discharged to a long-term care institution (14.0% vs 4.3%). Early dysphagia screening can effectively identify patients at higher risk of aspiration, which is associated with a greater risk of pneumonia, even if dysphagia screening was not associated with reduced rates of pneumonia or improvements in death or disability when tested in RCTs.109–111
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| New recommendation | An endoscopic evaluation is reasonable for those patients suspected of aspiration to verify the presence/absence of aspiration and to determine the physiological reasons for dysphagia to guide the treatment plan. | IIa | B |
| Instrumental evaluation (videofluoroscopy, fibreoptic endoscopic evaluation of swallowing or fibreoptic endoscopic evaluation of swallowing with sensory testing) allows the clinician to visualise swallow physiology, thus determining the presence or absence of aspiration, the quantity of aspiration, and the physiological or structural causes for dysphagia. This information is necessary for forming an appropriate and effective treatment plan, including swallow therapy and diet recommendations.113–115
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| New recommendation | It is reasonable for dysphagia screening to be performed by a speech/language pathology specialist or other trained healthcare providers. | IIa | C |
| Three RCTs evaluated computer-based therapy: one against no treatment, another against the same treatment provided by a speech and language therapist, and a third against non-linguistic computer training.116–118 These three trials concluded that computer-based therapy is feasible and efficacious. Therefore, computerised treatment is beneficial and can be used to supplement treatment provided by a speech/language pathologist. |
| New recommendation | It is not well established which instrument to choose for evaluation of swallowing with sensory testing. The choice may be based on instrument availability or other considerations (ie, fibreoptic endoscopic evaluation of swallowing, videofluoroscopy, fibreoptic endoscopic evaluation with sensory testing). | IIb | C |
| There is no consensus in the literature on a preferred instrumental study. Both videofluoroscopy and fibreoptic endoscopic evaluation of swallowing can be used to evaluate the swallow mechanism. Additionally, a large cohort study showed that fibreoptic endoscopic evaluation of swallowing with sensory testing was a relatively safe procedure for evaluating the sensory and motor aspects of dysphagia. Clinical judgement should be used to weigh the advantages and disadvantages of each study for each patient.119
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| Reworded | Maintaining oral hygiene may be a reasonable intervention to reduce the risk of post-stroke pneumonia. | IIb | B |
| 6.1.5 Prediction of infections |
| Reworded | Routine use of prophylactic antibiotics has no benefits. | III | B |
| Reworded | Routine placement of indwelling catheters is not recommended due to the potential increased risk of catheter-associated urinary tract infections. | III | C |
| New recommendation | Performing early swallowing function assessment and training for all patients with stroke can reduce the incidence of stroke-associated pneumonia. | I | B |
| A formal dysphagia screen is associated with a higher adherence rate to dysphagia screens and a significantly decreased risk of pneumonia.120
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| 6.1.6 Deep vein thrombosis (DVT) prophylaxis | | |
| Reworded | For patients who had a stroke with limited mobility and no contraindications, in addition to conventional treatment (aspirin and fluid therapy), intermittent pneumatic compression is recommended to reduce the risk of DVT. | I | B |
| Reworded | For patients with AIS with limited mobility, the benefit of prophylactic dose of subcutaneous heparin (unfractionated heparin (UFH) or LMWH) for DVT prophylaxis is not well established. | IIb | A |
| Reworded | The benefit-to-risk comparison between prophylactic doses of UFH and LMWH remains unclear. | IIb | B |
| Reworded | For patients with IS, elastic compression stockings are not routinely recommended. | III | B |
| New recommendation | The benefit of using rivaroxaban up to 45 days after discharge to prevent venous thromboembolism (VTE) for patients with AIS is unclear. | III | B |
| In the randomised, double-blind MARINER trial, medically ill patients who were at an increased risk of VTE based on a modified IMPROVE score of 4 or higher or a score of 2 or 3 plus a plasma D-dimer level of more than twice the upper limit of the normal range were assigned at hospital discharge to either once-daily rivaroxaban at a dose of 10 mg (with the dose adjusted for renal insufficiency) or placebo for 45 days.121 The results showed that rivaroxaban, given to medical patients for 45 days after hospital discharge, was not associated with a significantly lower risk of symptomatic VTE and death due to VTE than placebo (0.83% vs 1.10%, HR 0.76, 95% CI 0.52 to 1.09, p=0.14). The incidence of major bleeding was low. |
| New recommendation | Prolonging venous thromboprophylaxis for 4–5 weeks for patients with AIS can reduce the risk of VTE. | IIa | A |
| A 2020 meta-analysis for RCTs comparing extended versus standard venous thromboprophylaxis in patients hospitalised for AIS indicates that VTE risk was lower in patients with AIS receiving extended thromboprophylaxis (RR 0.67, 95% CI 0.43 to 1.04, 13 fewer per 1000), whereas the increase in major bleeding seemed trivial when compared with standard prophylaxis (RR 1.10, 95% CI 0.31 to 3.95, 1 more per 1000).122 The net clinical benefit may favour extended venous thromboprophylaxis for 4–5 weeks over standard thromboprophylaxis. |
| 6.1.7 Rehabilitation |
| Reworded | It is recommended providing early rehabilitative therapy within an organised interdisciplinary stroke care environment for patients who had a stroke. | I | A |
| Unchanged | It is recommended that stroke survivors receive rehabilitation at an intensity commensurate with anticipated benefit and tolerance. | I | B |
| Unchanged | High-dose, very early mobilisation within 24 hours of stroke onset should not be performed. | III | B |
| Reworded | It is recommended that all individuals with stroke be provided with a formal assessment of their activities of daily living and instrumental activities of daily living, communication abilities and functional mobility before discharge, and the findings be incorporated into the care transition and the discharge planning process. | I | B |
| Unchanged | A functional assessment by a clinician with expertise in rehabilitation is recommended for patients who had a stroke with residual functional deficits. | I | C |
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6.2 Management of neurological complications
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| 6.2.1 Brain oedema and occupation signs |
| Reworded | Patients with a large cerebral infarction are at high risk of developing brain oedema and increased intracranial pressure. Transferring these patients to the intensive care unit and implementing measures to mitigate the risk of oedema in the early post-stroke period are recommended. Close monitoring for signs of neurological deterioration in patients is crucial. | I | C |
| Reworded | In patients with unilateral MCA infarction, aged ≤60 years, who experience neurological deterioration within 48 hours despite receiving medical treatment, decompressive craniectomy with durotomy is reasonable. | IIa | A |
| Reworded | In patients with unilateral MCA infarction, aged >60 years, who experience neurological deterioration within 48 hours despite receiving medical treatment, decompressive craniectomy with durotomy may be considered. | IIb | B |
| Reworded | Although the optimal trigger for decompressive craniectomy is unknown, it is reasonable to consider the decline in consciousness caused by brain oedema as a criterion for surgical intervention. | IIa | A |
| Reworded | Ventriculostomy is recommended in the treatment of obstructive hydrocephalus after a cerebellar infarct. The decision to perform concurrent or subsequent decompressive craniectomy should be based on factors such as infarct volume, neurological condition, degree of brainstem compression and effectiveness of medical treatment. | I | C |
| Unchanged | Decompressive suboccipital craniectomy with durotomy should be performed in patients with cerebellar infarction causing neurological deterioration from brainstem compression despite maximal medical therapy. When deemed safe and indicated, obstructive hydrocephalus should be treated concurrently with ventriculostomy. | I | B |
| Unchanged | The use of salvage osmotic therapy for patients with clinical deterioration from occupying signs associated with large supratentorial infarction or cerebellar infarction is reasonable. | IIa | C |
| Reworded | Transient moderate hyperventilation (partial pressure of carbon dioxide target 30–34 mm Hg) as a bridging therapy is an appropriate treatment for patients with the acute severe neurological decline due to brain oedema. | IIa | C |
| Reworded | For patients with cerebral hemisphere or cerebellar infarction accompanied by brain oedema, using hypothermia or barbiturate drugs is not recommended. | III | B |
| Reworded | Because of a lack of evidence of efficacy and the potential to increase the risk of infectious complications, corticosteroids (in conventional or large doses) should not be administered to treat brain oedema and increased intracranial pressure. | III | A |
| 6.2.2 Haemorrhagic transformation |
| Unchanged | Symptomatic haemorrhagic transformation: stop using antithrombotic (antiplatelet, anticoagulation); for haemorrhage management associated with anticoagulation and thrombolysis, refer to cerebral haemorrhage treatment guidelines. | I | C |
| Unchanged | For patients with AIS with haemorrhagic transformation, starting or continuing antiplatelet or anticoagulant therapy should only be decided according to the specific clinical conditions and potential indications. | IIb | B |
| 6.2.3 Seizures after AIS |
| Reworded | The treatment of recurrent seizures following stroke should be similar to the management of seizures following other acute neurological conditions, with the selection of antiepileptic drugs based on individual patient characteristics. | I | C |
| New recommendation | In patients with epilepsy after IS, lamotrigine or levetiracetam monotherapy may be preferable to carbamazepine or sodium valproate monotherapy. | IIb | B |
| Recently, a cohort study investigated whether mortality varies with specific anti-seizure medication among patients with post-stroke epilepsy.123 Based on individual-level data from linked registers on all adults in Sweden, the study included 2577 patients receiving continuous anti-seizure medication monotherapy. The dispensed anti-seizure medication determined exposure status, and the first dispensation date marked the start of treatment. The primary outcome was all-cause death analysed using Cox proportional hazards regression with carbamazepine as the reference. This cohort study’s findings suggest differences in survival between patients treated with different anti-seizure medications for post-stroke epilepsy. Patients receiving lamotrigine monotherapy had significantly lower mortality (adjusted HR 0.76, 95% CI 0.61 to 0.95) than those receiving carbamazepine. The opposite applied to patients prescribed valproic acid, with a higher risk of cardiovascular and all-cause death (adjusted HR 1.40, 95% CI 1.19 to 1.64). Levetiracetam was associated with a reduced risk of cardiovascular death compared with carbamazepine (adjusted HR 0.77, 95% CI 0.60 to 0.99). However, there was no significant difference in overall mortality. |
| New recommendation | The SeLECT score is recommended to predict the risk of late seizures after IS. | I | B |
| The SeLECT is an easily applied instrument to predict late (>7 days) seizures after IS.124 The score consists of five variables: severity of stroke, large-artery atherosclerotic aetiology, early seizures, cortical involvement and territory of MCA involvement. The SeLECT score was developed based on five clinical predictors in 1200 participants who had an IS in Switzerland using backward elimination of a multivariable Cox proportional hazards model and externally validated in 1169 participants from three independent international cohorts in Austria, Germany and Italy, and assessed its performance with the concordance statistic and calibration plots. The lowest SeLECT value (0 points) was associated with a 0.7% (95% CI 0.4% to 1.0%) risk of late seizures within 1 year after stroke (1.3% (95% CI 0.7% to 1.8%) within 5 years), whereas the highest value (9 points) predicted a 63% (42% to 77%) risk of late seizures within 1 year (83% (62% to 93%) within 5 years). The model had an overall concordance statistic of 0.77 (95% CI 0.71 to 0.82) in the validation cohorts. Calibration plots indicated high agreement between predicted and observed outcomes. |
| New recommendation | Prophylactic use of anti-seizure drugs is not recommended. | III | C |
| No studies to date have demonstrated the benefit of prophylactic anticonvulsant use after IS. |